Provider Demographics
NPI:1629561840
Name:DESLOOVER, KATIE REGENA
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:REGENA
Last Name:DESLOOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3393 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:MI
Mailing Address - Zip Code:48145-9638
Mailing Address - Country:US
Mailing Address - Phone:614-778-3660
Mailing Address - Fax:
Practice Address - Street 1:14930 LAPLAISANCE RD STE 118
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-3878
Practice Address - Country:US
Practice Address - Phone:734-888-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist